An Approach to the Patient with Neck Pain
Transcript of An Approach to the Patient with Neck Pain
![Page 1: An Approach to the Patient with Neck Pain](https://reader034.fdocuments.net/reader034/viewer/2022052105/628711f685fcd15f851842b7/html5/thumbnails/1.jpg)
Medical Research Archives, Vol. 5, Issue 5, May 2017
An Approach to the Patient with Neck Pain
Copyright 2017 KEI Journals. All Rights Reserved Page │1
An Approach to the Patient with Neck Pain
Authors:
Christopher D. Geiger, D.O.
Michael W. Devereaux, M.D.
Affiliations:
Department of Neurology, University
Hospitals- Cleveland Medical Center,
Cleveland, OH
Correspondence address:
Christopher D. Geiger, D.O.
E-mail:
Abstract
In the United States, neck pain is an extremely
common reason for seeking medical attention.
While symptoms can occur abruptly, they are often
more indolent in their course, usually without any
temporal relationship to trauma or other inciting
events. For these reasons, physicians need to be
well-versed in the initial evaluation and
management of these complaints. It is important to
have a working knowledge of the cervical anatomy,
the differential diagnosis for neck pain, and the
potential mimics which may present. It is equally
imperative to hone the skills necessary to
effectively differentiate localized, mechanical neck
pain syndromes from those of a more serious
etiology. To that end, identifying “red flags” during
the patient’s history and performing a focused
musculoskeletal and neurological examination is
critical to triaging the patient appropriately. As the
U.S. health care system moves away from
traditional fee-for-service reimbursement, greater
emphasis will be placed on providing high-quality,
cost-conscious care. Physicians must be deliberate
when evaluating a patient with neck pain, rather
than ordering a “one size fits all” battery of tests.
Knowing when to order advanced imaging
modalities or refer a patient to a specialist will be
paramount in providing the best patient care while
responsibly utilizing resources.
Keywords: Neck pain; radiculopathy; myelopathy;
chronic pain; spondylosis
![Page 2: An Approach to the Patient with Neck Pain](https://reader034.fdocuments.net/reader034/viewer/2022052105/628711f685fcd15f851842b7/html5/thumbnails/2.jpg)
Medical Research Archives, Vol. 5, Issue 5, May 2017
An Approach to the Patient with Neck Pain
Copyright 2017 KEI Journals. All Rights Reserved Page │2
1. What is the prevalence of neck
pain?
Neck pain is the fourth leading cause of
disability in the United States [18]. Reduced
productivity related to neck pain and other
musculoskeletal disorders has been estimated
to cost $61.2 billion annually [25]. It is
expected that about two thirds of Americans
will experience a significant episode of neck
pain at some point in their life [4,7,9]. A
recent study estimated that, over a 3-month
period, 9 million Americans were affected by
new-onset neck pain with an additional 19
million citing both neck and back pain [26].
The incidence rises as people grow older, but
plateaus in middle-age. Women are more
often affected than men (chart 1) [4,6,14,20].
2. What are the risk factors for neck
pain?
As one might expect, the risk factors
for acute onset neck pain and chronic neck
pain vary considerably. Abrupt, new onset
pain tends to be associated with exposure to
certain events (e.g. rear-end automobile
accidents, sporting injuries). However, as
will be discussed later, this pain is generally
self-limited. There is an expanding literature
exploring the subset of people in which acute
neck pain does not resolve, but rather
transforms into chronic pain [24,26,27].
Frequently identified risk factors include
high body mass index, frequent neck
extension during the day, psychologically
demanding jobs, insomnia, tobacco use and a
sedentary lifestyle [24,26]. A variety of
psychosocial factors often seem to have an
impact as well. Concurrent depression,
anxiety or somatization tendencies seem to
play a significant role in the evolution of
chronic musculoskeletal pain [26, 27].
Chart 1. Source: National health interview survey, 2007
0
2
4
6
8
10
12
14
16
18
TOTAL 20-39 40-64 65+
11
8
13 12
15
12
18 16
% o
f A
du
lts
Age (years)
3-Month Prevalence of Neck Pain in Adults
Men Women
![Page 3: An Approach to the Patient with Neck Pain](https://reader034.fdocuments.net/reader034/viewer/2022052105/628711f685fcd15f851842b7/html5/thumbnails/3.jpg)
Medical Research Archives, Vol. 5, Issue 5, May 2017
An Approach to the Patient with Neck Pain
Copyright 2017 KEI Journals. All Rights Reserved Page │3
3. What is the relevant anatomy and
its common pathology?
The cervical spine must be rigid
enough to support the head and strong
enough to protect the indwelling spinal cord,
yet sufficiently flexible to allow for
movement in multiple planes. This is a
difficult task and one that places the region
at great risk for injury. The articulation
between the occiput and the first cervical
vertebra is responsible for approximately
one third of neck flexion and extension and
one half of lateral motion in the neck. The
articulation between the first and second
cervical vertebra allows for 50% of
rotational range of motion. The articulations
between the second and seventh cervical
vertebrae allow for approximately two thirds
of flexion and extension, 50% of rotation,
and 50% of lateral motion. It is this region
where the highest proportion of cervical
disease occurs. Ironically, it is the structures
intended to protect the spinal cord and
nerves which ultimately inflict the most
damage. Uncovertebral joints (joints of
Luschka) span from the C3 to the C7
vertebrae. With age, these joints
hypertrophy and, as a result, narrow the
intervertebral foramen which may impinge
on the exiting spinal nerves. The
ligamentum flavum is in actuality a series of
ligaments which run the length of the
posterior aspect of the spinal canal,
connecting the laminae of adjacent
vertebrae. This structure contributes to the
alignment and integrity of the spinal
column, but also has elastic components
which assist the cervical musculature in
maintaining a neutral head position. Over
time, with repeated rupture and
regeneration, these ligaments can
hypertrophy and result in narrowing of the
central canal (cervical spinal stenosis).
The “shock absorbers” of the spine,
the intervertebral discs, are one of the more
frequent generators of neck pain. A review
of MRI scans recently revealed disc
extrusions in 20% of asymptomatic patients
between the ages of 40 and 55 years [10].
These herniations are typically directed in a
posterolateral direction due to the presence
of the posterior longitudinal ligament. As a
result, this pathology tends to affect the
exiting nerve root, resulting in cervical
radiculopathy. On occasion, the disc may be
more broad-based or may extend directly
posterior by way of an annular tear
(disruption of the annulus fibrosis). In these
cases, there may be central canal stenosis
and myelopathy.
The normal cervical lordosis is known
as a “secondary curvature,” not appearing
until several months after birth. This is a
compensatory curve which helps to shift the
weight of the head directly over the lower
extremities, in line with the body axis. This
natural curvature can be lost or even
reversed in patients with significant
degenerative disease. These changes place
the neck at a mechanical disadvantage,
forcing other structures such as the trapezius
and paraspinal muscles to play a larger role
in maintaining appropriate posture. While
there isn’t much support in the literature, it
would stand to reason that this would be a
common generator of neck pain. As might
be expected, these anatomical alterations
tend to occur in concert, precipitating neck
pain which is thus multifactorial in etiology.
This results in cervical spondylosis, a
diagnosis covering a broad array of arthritic
and degenerative conditions that ultimately
translates to “a bad neck.”
4. What are the essentials in the
history that help to define the nature of
the neck pain?
While neck pain onset is often
insidious, special attention is required in
cases of newly diagnosed pain or when there
![Page 4: An Approach to the Patient with Neck Pain](https://reader034.fdocuments.net/reader034/viewer/2022052105/628711f685fcd15f851842b7/html5/thumbnails/4.jpg)
Medical Research Archives, Vol. 5, Issue 5, May 2017
An Approach to the Patient with Neck Pain
Copyright 2017 KEI Journals. All Rights Reserved Page │4
is an abrupt change in quality or severity of
established neck pain. Obtaining the history
is not unlike other complaints, though
certain questions are of great importance.
One must assess the acuity of the symptoms
and their relationship to any particular
trauma or activity. What is the quality of
the pain? Where is the location of greatest
discomfort? For example, anterior neck pain
is uncommon in musculoskeletal injury and
should prompt other investigations. What
time of day is it most intense? Mechanical
pain is typically worse at the end of the day,
while inflammatory conditions may be
worse in the morning. Is it well-localized or
does it radiate to another region? Are there
mitigating factors? Radicular pain may be
provoked by increases in intrathoracic
pressure (e.g. coughing, sneezing, Valsalva).
Are the symptoms alleviated by certain
body positions? As with low back pain, if
the pain is not reduced by recumbency,
vertebral column infections and metastatic
cancer should be considered [3,11,15].
The key to the interview is to screen
for conditions which could potentially lead
to significant morbidity if missed. Patients
with prominent pain may complain of that
alone. It is the responsibility of the
physician to probe for other
symptomatology which the patient may not
readily volunteer. The examiner must
inquire about disturbances of bowel or
bladder function, sensory changes in the
lower extremities, muscle weakness or
imbalance, all of which could be the
sequelae of a compressed cervical spinal
cord. Keep in mind that cord compression in
and of itself is not usually painful, but can
occur in association with a painful cervical
radiculopathy. Take care not to be
preoccupied with shooting upper extremity
pain and miss the so-called “long-track”
symptoms of myeloradiculopathy. While the
majority of neck pain is musculoskeletal or
neurologic in origin, one must also be wary
of other general medical symptoms such as
weight loss, persistent fevers or night
sweats. A careful review of systems should
be completed looking for any evidence of
constitutional signs which may lead to a
broader differential diagnosis.
5. What are the essentials of the
physical examination?
The examination begins with
inspection. If the neck pain is the result of
recent significant trauma, the neck should be
stabilized and imaged before commencing
the physical examination (see imaging
below). Once the spine is “cleared,” an
examination can be performed. Findings of
reduced spontaneous head movement, head
tilt and deformity in the natural neck
curvature all raise the possibility of an
underlying vertebral column disorder.
Tenderness on palpation and restricted
passive range of motion are sensitive
markers of cervical spine disease, but very
non-specific. This may be due to guarding,
associated muscle spasm/injury or even
focal dystonia. A thorough neurological
assessment is needed to differentiate
isolated axial pain syndromes from those of
a more significant cause. Manual power
testing should be performed to identify focal
weakness, particularly if it occurs in a
myotomal distribution. Depressed upper
extremity reflexes can occur with cervical
radiculopathy and again are generally root-
specific (table 1). Lower motor neuron
findings (e.g. weakness, hyporeflexia) not
limited to a specific myotomal pattern may
suggest multi-root involvement (i.e.
polyradiculopathy) or potentially a brachial
plexopathy- which can present with neck
pain as well. These entities can be difficult
to distinguish on clinical examination alone
and, as we will discuss below, additional
investigations are often needed. Brisk
reflexes in the lower extremities are
![Page 5: An Approach to the Patient with Neck Pain](https://reader034.fdocuments.net/reader034/viewer/2022052105/628711f685fcd15f851842b7/html5/thumbnails/5.jpg)
Medical Research Archives, Vol. 5, Issue 5, May 2017
An Approach to the Patient with Neck Pain
Copyright 2017 KEI Journals. All Rights Reserved Page │5
suggestive of spinal cord pathology as are a
number of other pathological reflexes.
Passive muscle tone or spasticity must be
assessed as another valuable tool in
distinguishing upper and lower motor
neuron pathology. A thorough sensory
examination should be completed both
assessing for dermatomal loss (table 1) as
well as screening for a sensory cord level on
the back and chest. When suspicion for cord
involvement is high, assessment of rectal
tone is important. There are several special
tests or “provocative maneuvers” which are
particularly helpful in evaluating a patient
with neck pain [15]:
• Modified Spurling’s maneuver: The
head is extended, rotated toward the
side of the pain and laterally flexed
toward the side of pain. An axial load
is then placed downward on the head.
If this induces radiating pain and
paresthesia into the symptomatic
extremity, it is highly specific for
nerve root compression, usually
secondary to disc herniation.
• Traction ‘‘distraction’’ test: Placing
vertical upward traction on the head
may relieve cervical spinal nerve
compression reducing upper extremity
pain and paresthesia.
• Valsalva test: As with low back
pain/sciatica, the Valsalva maneuver
with resultant increased intrathecal
pressure can sometimes accentuate
neck and upper extremity symptoms
when due to an underlying cervical
radiculopathy.
• Lhermitte’s test: In patients with
myelopathy that impacts the posterior
columns, neck flexion may produce
paresthesia, usually in the back, but
sometimes into the extremities. The
Lhermitte’s sign is most commonly
associated with an inflammatory
process such as with multiple
sclerosis, but it is sometimes noted
with spinal cord compression.
Once again, these maneuvers should
only be performed in non-traumatic cases or
in situations where this is little chance of
skeletal instability.
Table 1. Roots of the brachial plexus with their associated myotome and dermatome.
Root Weakness Sensory Loss Reflex
C5 Shoulder abduction,
elbow flexion
Lateral arm Biceps,
Brachioradialis
C6 Shoulder abduction,
elbow flexion
Lateral forearm,
first digit, second
digit
Biceps,
Brachioradialis
C7 Elbow extension,
wrist extension,
finger extension
Middle finger Triceps
C8 Finger abduction,
adduction
Medial forearm,
fourth digit, fifth
digit
N/A
![Page 6: An Approach to the Patient with Neck Pain](https://reader034.fdocuments.net/reader034/viewer/2022052105/628711f685fcd15f851842b7/html5/thumbnails/6.jpg)
Medical Research Archives, Vol. 5, Issue 5, May 2017
An Approach to the Patient with Neck Pain
Copyright 2017 KEI Journals. All Rights Reserved Page │6
6. What imaging modalities are used
to evaluate neck pain and when should
they be ordered?
Caution must be exercised with
ordering imaging of the cervical spine
because asymptomatic herniated discs and
spondylotic changes are common and may
be seen particularly in older patients with
unrelated non-radiating neck and low back
pain [5]. Reliance on imaging results alone
may lead to additional unnecessary testing or
even unsuccessful surgery. In an effort to
avoid these situations, imaging should
always be ordered as a confirmatory test to
investigate a clinician’s suspicion for a
particular disease which is based on the
history and physical examination. The
routine ordering of imaging as a substitute
for a complete history and physical
examination may often reveal
“incidentalomas” which confound the
workup and exhaust resources. Trauma is the
exception to this general principle, as a full
examination is often not possible due to
concerns about cervical instability.
Radiographs are affordable and useful in
assessing for skeletal abnormalities such as
atlanoaxis subluxation, Klippel-Feil
syndrome or vertebral compression
fractures. While plain films are often ordered
to assess for neuroforaminal or spinal
stenosis, the findings are generally very
inaccurate. MRI is the modality of choice
when investigating cervical radiculopathy or
central canal stenosis of any etiology. CT
scan is often appropriate for a patient with a
suspected occult fracture (because of severe
guarding or spinous process point-
tenderness) and it is superior to MRI in this
regard [2].
Image 1. MRI cervical spine, T2 weighted imaging. A) Midline sagittal image demonstrating
multi-level central canal stenosis with spinal cord compression due to broad-based disc
herniations at C4/C5 and C5/C6. B) Axial image at the level of the C3/C4 disc space. C) Axial
image at the level of the C4/C5 disc space demonstrating extruded disc material (arrow) which
obliterates the normal bright CSF signal and deforms the spinal cord.
![Page 7: An Approach to the Patient with Neck Pain](https://reader034.fdocuments.net/reader034/viewer/2022052105/628711f685fcd15f851842b7/html5/thumbnails/7.jpg)
Medical Research Archives, Vol. 5, Issue 5, May 2017
An Approach to the Patient with Neck Pain
Copyright 2017 KEI Journals. All Rights Reserved Page │7
7. How do cervical radiculopathies
present and how are they best managed?
The most common reason for an acute
cervical radiculopathy is an intervertebral
disc herniation [1]. These injuries may be
brought on by an identifiable event, but
others seem to occur sporadically. With
regard to the relationship between the
cervical roots and the cervical vertebrae,
each numbered cervical root passes through
the foramen above the numbered cervical
vertebra, this is of particular importance
when evaluating imaging studies. For
example, the C6 spinal nerve exits through
the foramen between the C5 and C6
vertebrae. The level of disc
herniation/radiculopathy is as follows [22]:
• C6–C7 compressing the C7 root: 45%
to 60%
• C5–C6 compressing the C6 root: 20%
to 25%
• C8–T1 compressing the C8 root:
approximately 10%
• C4–C5 compressing the C5 root:
approximately 10%
Initial symptoms after disc herniation
with radiculopathy are generally neck pain
and stiffness. The pain tends to evolve,
eventually radiating into the shoulder,
scapula or upper extremity. The exact
distribution depends on the particular root(s)
involved. Other symptoms include
paresthesia, hyperesthesia and weakness.
Sensory disturbances are generally
dermatomal in distribution, with the greatest
involvement often predominately affecting
the distal portion of the involved dermatome.
When a disc herniation is responsible, the
natural course of the condition is typically
self-limited with 75-90% improving without
surgery. The disk material eventually
resorbs, alleviating the pressure on the
adjacent nerve root. Patients without
concurrent myelopathy or significant
weakness should be treated conservatively
for at least six weeks. The cornerstones of
conservative management are
immobilization, nonsteroidal anti-
inflammatory medication and physical
therapy [29]. Epidural steroid injections are
more controversial. A systematic review of
34 recent studies demonstrated that
injections with local anesthetic and steroids
can result in pain intensity reduction and
improved functional status, but these
interventions should be considered on a case
by case basis [12]. If the patient has
significant weakness within a given cervical
myotome, a prompt workup is usually
indicated, including MRI of the cervical
spine and possibly electromyography with
nerve conduction studies of the symptomatic
limb and ipsilateral paracervical muscles.
Surgery is typically reserved for those
who have a significant functional deficit,
incapacitating pain or fail to improve with
medical management. Surgical options
include anterior cervical discectomy alone,
laminectomy with discectomy, discectomy
with fusion, disc arthroplasty (implanting an
artificial cervical disc) and posterior
foraminotomy [29]. Comparisons of the
various surgical techniques are beyond the
scope of this article and best left for the
surgeon to discuss with the patient. It should
be noted, however, that when surgery is
performed, the alteration of the spinal
mechanics may place adjacent vertebral
levels at risk for accelerated degenerative
disease. When cervical radiculopathy is
caused by osteophytes as seen in
spondylosis, they are much less likely to
remit without intervention. In these cases,
the risks and benefits of surgery need to be
carefully evaluated.
![Page 8: An Approach to the Patient with Neck Pain](https://reader034.fdocuments.net/reader034/viewer/2022052105/628711f685fcd15f851842b7/html5/thumbnails/8.jpg)
Medical Research Archives, Vol. 5, Issue 5, May 2017
An Approach to the Patient with Neck Pain
Copyright 2017 KEI Journals. All Rights Reserved Page │8
8. How do patients with cervical
canal stenosis present?
In isolation, cervical myelopathy can
often be painless and, early on, minimally
symptomatic. Patients often present with
“unsteadiness,” leg stiffness or even mild
foot numbness. About 80% of people by age
50 and virtually 100% of people by age 70
have radiologic evidence of cervical
spondylosis [15]. A mid-cervical canal
sagittal diameter of 12 mm or less is
generally associated with the development of
myelopathy. Although stenosis and resultant
myelopathy can be caused by many
pathologic processes, including trauma with
resultant hyperextension in the presence of
congenital stenosis (a concern in contact
sports) and central disc herniation, the most
common cause is spondylosis (degeneration)
[16]. Degenerative changes combining any
of the following: osteophytes, herniating
discs, facet joint hypertrophy, ossified
posterior longitudinal ligament and
thickened ligamentum flavum can produce
cervical myelopathy in the absence of
dramatic cervical canal stenosis. In addition
to myelopathy as a result of direct cord
compression, there can be a compromise of
perfusion in the distribution of the anterior
spinal artery (which is located on the
outermost surface of the cord) with resultant
ischemic myelopathy [13]. Crandall and
colleagues [8] described five distinct cord
syndromes representing relatively advanced
disease, as follows:
• Brown-Sequard syndrome (as a result
of hemicord injury)
• Central cord syndrome, with motor
and sensory deficits more marked in
the upper extremities than the lower
extremities
• Motor system syndrome resembling
amyotrophic lateral sclerosis by virtue
of lower motor neuron changes in the
upper extremities and upper motor
neuron changes in the lower
extremities in the absence of
significant sensory deficit
• Brachialgia and cord syndrome
(myeloradiculopathy), characterized
by upper extremity radicular
distribution pain and an admixture of
upper and lower motor neuron
weakness in the extremities
• Transverse myelopathy, the most
common, appearing suddenly or
evolving from one of the preceding
syndromes; all ascending and
descending tracts are involved and
sphincter involvement is common
These syndromes generally are not
clearly defined early in the course of cervical
myelopathy. Symptoms are often subtle at
onset and recognition is difficult.
Hyperreflexia and extensor plantar responses
(Babinski sign), minimal weakness in the
lower extremities, and a subtle gait
disturbance are common early signs [16].
Other patients may only experience mild
foot numbness. These patients are often
erroneously evaluated for peripheral
polyneuropathy. The key to avoiding this all
too common error is assessing for the
presence or absence of ankle reflexes. While
the presence of an Achilles reflex is a
normal finding in most people, this response
would not be expected in a person with a
suspected large-fiber peripheral
polyneuropathy. Distal lower extremity
numbness in a patient with retained ankle
reflexes may be suggestive of upper motor
neuron pathology. Lhermitte’s sign may be
present early in some patients. Subtle
clumsiness and paresthesia in the hands may
be the only initial symptoms and can be
confused with median and ulnar
mononeuropathies [28].
![Page 9: An Approach to the Patient with Neck Pain](https://reader034.fdocuments.net/reader034/viewer/2022052105/628711f685fcd15f851842b7/html5/thumbnails/9.jpg)
Medical Research Archives, Vol. 5, Issue 5, May 2017
An Approach to the Patient with Neck Pain
Copyright 2017 KEI Journals. All Rights Reserved Page │9
9. What are the causes and
treatments for non-radiating neck pain?
Once significant neurologic
comorbidities can been ruled out as a cause
of neck pain, the focus shifts to identifying
the specific etiology of the localized neck
pain. A number of conditions can present in
this fashion including: neck strains, cervical
facet syndrome and myofascial pain
syndrome. It is often difficult to identify the
precise instigator, as symptoms are often
vaguely defined and overlap. In these
patients, diagnostic testing is low yield. That
said, after several weeks of unrelenting pain,
diagnostic testing may prove necessary to
rule out the unexpected. Acute, localized
neck pain typically resolves within days or
weeks. Evidence regarding the efficacy of
individual interventions for neck pain is
often contradictory because of poor quality
trials and the tendency to combine therapies.
Treatment of acute non-radiating neck pain
is largely empiric and may include the
following [15]:
• Pain avoidance, which, if necessary,
may include a short period of bed rest.
A cervical pillow or towel rolled up
and placed under the neck in bed may
help. Long-term bed rest is to be
avoided.
• Medications including acetaminophen,
non-steroidal anti-inflammatory drugs
(NSAIDs), pain medication when
necessary, and possibly muscle
relaxants.
• Local application of heat or cold if
either modality proves helpful to the
patient while recognizing the lack of
“science” to support either.
In the case of chronic neck pain, as
with any chronic pain syndrome, it is crucial
to avoid the regular use of reactive pain
medications, particularly potentially
addictive analgesics. The overuse of
analgesics, even non-addictive analgesics,
may lead to analgesic rebound pain. Given
the increasingly convincing association
between chronic neck pain and
psychological comorbidities there may be a
role for antidepressant medication,
especially those known to have benefit in the
treatment of neuropathic pain, such as
duloxetine. To that same end, there is some
recent evidence that cognitive-behavioral
therapy (CBT) is better at pain reduction
than other interventions for neck pain lasting
more than three months [17]. Physical
therapy and regular aerobic exercise is
particularly important in management of
these patients.
10. What if it’s not just the neck?
What associated conditions are important
to be aware of?
There are a number of other conditions
that may produce neck pain, but the
generator may not be the cervical vertebrae
or related structures. Herpes zoster can
present with severe neck and/or occipital
pain often within a C2-C4 dermatomal
distribution. Keep in mind that the onset of
pain can precede the rash eruption.
Rheumatoid arthritis can produce neck pain,
stiffness and impaired range of motion. In
advanced cases is may erode the transverse
ligament, allowing for atlantoaxial
subluxation. If this goes undiagnosed, the
dens may move anteriorly compressing the
spinal cord producing a myelopathy and
possibly respiratory failure. Ankylosing
spondylitis can also produce neck pain and
rarely, atlantoaxial subluxation. Any
mechanical instability of the high cervical
spine should be considered a surgical
emergency. Locally invasive processes such
as malignancy or infection should be
considered under appropriate circumstances.
The walls of cervical blood vessels contain
![Page 10: An Approach to the Patient with Neck Pain](https://reader034.fdocuments.net/reader034/viewer/2022052105/628711f685fcd15f851842b7/html5/thumbnails/10.jpg)
Medical Research Archives, Vol. 5, Issue 5, May 2017
An Approach to the Patient with Neck Pain
Copyright 2017 KEI Journals. All Rights Reserved Page │10
nociceptive nerve fibers, thus vertebral or
carotid dissections may present with acute
neck pain. For similar reasons, giant cell
(temporal) arteritis or coronary artery
ischemia may present as primary neck pain.
Pain from the brachial plexus can often
mimic pain in the spine. These disorders
may be inflammatory (neurogenic
amyotophy), infiltrative (lymphoma), or
compressive (Pancoast tumor). An
examination that yields motor or sensory
deficits affecting the upper extremity and not
fitting a clear root distribution may need
further investigation with contrast-enhanced
MRI and electrodiagnostic studies. Lastly,
pain from the shoulder joint can often radiate
into the upper extremity in a “radicular”
fashion. In this setting, there will be no
abnormal findings on motor, sensory and
reflex testing. Furthermore, passive
movement of the shoulder may exacerbate
symptoms.
11. Conclusion
New onset neck pain is a frequently
encountered complaint in the primary care
setting. Often pain begins sporadically, with
no clearly identifiable precipitating event.
While most cases are self-limited in their
natural course, physicians must be able to
efficiently and reliably recognize the patient
whose symptoms are atypical and warrant
further investigation. Any patient with neck
pain needs a focused neurological
assessment. Imaging and other diagnostic
testing should be reserved to confirm
neurological complications rather than
search for them. As the landscape of modern
medicine continues to shift, the ability to
take an appropriate history and perform a
competent physical examination will always
be the foundation of good clinical medicine.
![Page 11: An Approach to the Patient with Neck Pain](https://reader034.fdocuments.net/reader034/viewer/2022052105/628711f685fcd15f851842b7/html5/thumbnails/11.jpg)
Medical Research Archives, Vol. 5, Issue 5, May 2017
An Approach to the Patient with Neck Pain
Copyright 2017 KEI Journals. All Rights Reserved Page │11
References
1. Algren B, Garfen S. Cervical
radiculopathy. Orthop Clin North Am
1996; 27: 253–63.
2. Anderson SE, Boesch C, Zimmerman
H, et al. Are there cervical spine
findings at MR imaging that are
specific to acute symptomatic
whiplash injury. Radiology 2012;
262(2): 567-75.
3. Anonymous. Scientific approach to the
assessment and management of
activity related spinal disorders: a
monograph for clinicians. Report of
the Quebec task force on spinal
disorders. Spine 1987; 12:S1–59.
4. Binder A. Neck Pain. Clinical
Evidence 2008; 8: 1103.
5. Boden SD, McCown PR, Davis DO, et
al. Abnormal magnetic-resonance
scans of the cervical spine in
asymptomatic subjects. The Jour of
Bone and Joint Surg 1990; 1178-84.
6. Cote P, Cassidy JD, Carrole J, et al.
The factors associated with neck pain
and its related disability in the
Saskatchewan population. Spine 2000;
25:1109–17.
7. Cote P, Cassidy JD, Carroll L, et al.
The Saskatchewan health and back
pain survey: the prevalence of neck
pain and related disability in
Saskatchewan adults. Spine 1998;
1689–98.
8. Crandall P, Batzdorf U, Conrad D, et
al. Cervical spondylotic myelopathy. J
Neurosurg 1996; 25:57–66.
9. Croft PR, Lewis M, Papgeogiou AC,
et al. Risk factors for neck pain: a
longitudinal study in the general
population. Pain 2001; 93:317–25.
10. D’Antoni AV, Croft AC. Prevalence
of herniated intervertebral disc of the
cervical spine in asymptomatic
subjects using MRI scans: a qualitative
systematic review. Jour of Whiplash &
Related Disord 2006; 5(1).
11. Deyo RA, Cherkin D, Conrad D, et al.
Cost, controversy, crisis: low back
pain and the health of the public. Annu
Rev Public Health 1992; 12:141–55.
12. Diwan S, Manchikanti L, Benyamin
RM, et al. Effectiveness of cervical
epidural injections in the management
of chronic neck and upper extremity
pain. Pain Physician 2012; 15(4):
e405-34.
13. Fehlings M, Skaf G. A review of the
pathophysiology of cervical
spondylotic myelopathy with insights
for potential novel mechanisms drawn
from traumatic spinal cord injury.
Spine 1998; 23:2730–7.
14. Fejer R, Kyvik KO, Hartvigsen J. The
prevalence of neck pain in the work
population: a systematic critical review
of the literature. Eur Spine Jour 2006;
15: 834-48.
15. Levin KH, Covington EC, Devereaux
MW, et al. Neck and low back pain.
Continuum (NY) 2001; 7:1–205.
16. McCormack B, Weinstein P. Cervical
spondylosis: an update. West J Med
1996; 165:43–51.
17. Monticone M, Cedraschi C,
Ambrosini, et al. Cognitive-
behavioural treatment for subacute and
chronic neck pain. Cochrane Database
of System Rev 2015; 5: CD010664.
18. Murray, JL. The state of US health,
1990-2010: Burden of diseases,
![Page 12: An Approach to the Patient with Neck Pain](https://reader034.fdocuments.net/reader034/viewer/2022052105/628711f685fcd15f851842b7/html5/thumbnails/12.jpg)
Medical Research Archives, Vol. 5, Issue 5, May 2017
An Approach to the Patient with Neck Pain
Copyright 2017 KEI Journals. All Rights Reserved Page │12
injuries and risk factors. JAMA 2013;
310(6): 591-608.
19. Nahin RL. Estimates of pain
prevalence and severity in adults:
United States, 2012. Jour of Pain 2015;
16(8): 769-80.
20. National health interview survey
(NHIS). 2007.
21. Park SJ, Lee R, Yoon DM, et al.
Factors associated with increased risk
for pain catastrophizing in patients
with chronic neck pain: a retrospective
cross-sectional study. Medicine
(Baltimore) 2016; 95(37): e4698.
22. Radhakrishnan K, Litchy W, O’Fallon
W, et al. Epidemiology of cervical
radiculopathy: a population-based
study from Rochester, Minnesota,
1976 through 1990. Brain 1994;
117:325–35.
23. Shahidi B, Curran-Everett D, Maluf
KS. Psychosocial, physical and
neurophysiological risk factors for
chronic neck pain: a prospective
inception cohort study. The Jour of
Pain 2015; 16(12): 1288-99.
24. Sihawong R, Sitthipornvorakul E,
Paksaichol A, Janwantanakul P.
Predictors for chronic neck and low
back pain in office workers: a 1-year
prospective cohort study. Jour Occup
Health 2016; 58: 16-24.
25. Stewart WF, Ricci JA, Chee E, et al.
Lost productive time and cost due to
common pain conditions in the US
workforce. JAMA 2003; 290: 2443-54.
26. Strine TW, Hootman JM. US national
prevalence and correlates of low back
and neck pain amound adults. Arthritis
& Rheumatism 2007; 57(4): 656-65.
27. Vargas-Prada S, Coggon D.
Psychological and psychosocial
determinants of musculoskeletal pain
and associated disability. Best Pract
Res Clin Rheumatol 2015; 29(3): 374-
90.
28. Voskuhl R, Hinton R. Sensory
impairment in the hands secondary to
spondylotic compression of the
cervical spinal cord. Arch Neurol
1990; 47:309–11.
29. Woods BI, Hilibrand AS. Cervical
radiculopathy: epidemiology, etiology,
diagnosis and treatment. Jour Spinal
Disord Tech 2015; 28(5): e251-9.